Psychiatric Practice Financial Policy Agreement

Patient Information

Name: _________________________ Date of Birth: _____________ Chart Number: __________________ Date: ____________________

Financial Responsibility Agreement

1. Insurance and Payment Terms

• I understand that I am financially responsible for all charges, whether covered by insurance or not
• I agree to provide current insurance information and notify the practice of any changes
• Co-payments are due at the time of service
• Self-pay rates are payable in full at time of service

2. Appointment Policies

• 48-hour cancellation notice is required
• Late cancellations or no-shows will incur a fee of $___
• Repeated no-shows may result in discharge from the practice

3. Insurance Claims

• The practice will submit claims to my insurance carrier
• I authorize payment of benefits directly to [Practice Name]
• I understand that some services may not be covered by insurance

4. Outstanding Balances

• Balances over 30 days old incur a monthly service charge of ____%
• Accounts over 90 days past due may be referred to collections
• I agree to pay all collection costs if applicable

5. Medication Management

• Prescription refill requests outside of appointments may incur a fee
• Prior authorization processing fees may apply

Acknowledgment

I have read and understand the financial policy of [Practice Name]. I agree to comply with these terms and accept responsibility for any payment due.

Signature: _________________________ Date: ____________

Print Name: ________________________

Practice Representative: _____________ Date: ____________